QPP SURS Newsletter January 2020

QPP SURS Quality Payment Program


  1. Upcoming Events
  2. Reminder: Submit your 2019 MIPS Data by March 31st, 2020
  3. MIPS New Year’s Resolutions: Best Practices for 2020
  4. Tips for Coding Claims for 2020 MIPS Quality Measures
  5. How to Connect to Public Health Registries and Clinical Data Exchanges
  6. Monthly Observance: Cervical Health Awareness Month

Upcoming Events

Doctor Talking to Patient


February 2020 LAN Webinar: Submitting your 2019 MIPS Data

Additional Upcoming Events and Links to Past Events

Reminder: Submit your 2019 MIPS Data by March 31, 2020

As of January 2, 2020, you can now submit your 2019 MIPS data. As a reminder, March 31, 2020 is the final day to submit 2019 MIPS data to CMS for all performance categories. To assist you with your submission, please refer to the following resources and guidance:

Finally, remember that Technical Assistance Contractors (TACs) are available to provide you with free personalized support through the March 31 deadline and beyond. Find your TAC here.

MIPS New Year’s Resolutions: Best Practices for 2020

Welcome to Year 4 of MIPS! As we embark on a new reporting year, it is important to start planning and preparing your practice for data collection and reporting. Use the following tips and reminders to start the year on the right track and maximize your MIPS score in 2020.

1) Review your past performance feedback

  • Reviewing your past performance feedback can help you identify where to devote resources to improve your score in 2020. Your cost score feedback can be particularly helpful in identifying patients with high health care costs, and finding strategies to improve care while lowering costs for these patients. In 2019, CMS provided beneficiary-level cost data reports for viewing and download by clinicians and groups who were scored on the MIPS Total Per Capita Costs for All Attributed Beneficiaries (TPCC) measure and the MIPS Medicare Spending per Beneficiary (MSPB) cost measure in 2018. These data may be used to identify care coordination opportunities for your beneficiaries and streamline resource use.

2) Understand what changed from 2019

3) Consider and select your 2020 measures

  • Make sure your MIPS quality measures aren’t topped out by reviewing the 2020 Quality Benchmarks file.  For more information on MIPS quality measures, review the 2020 MIPS Clinical Quality Measure Specifications and Supporting Documents, or the 2020 Medicare Part B Measures Specifications and Supporting Documents if you are reporting via claims.
  • There are two new improvement activities available to report in 2020 and seven activities that were revised. For more information, see the 2020 Improvement Activities Inventory.
  • If applicable, review the measures available for reporting in your electronic health record (EHR) as well as the capabilities for reporting objectives in the Promoting Interoperability performance category (e-Prescribing, Health Information Exchange, Provider to Patient Exchange, Public Health and Clinical Data Exchange.)
  • Look for bonus points – If you report additional high priority quality measures, you can earn two bonus points per measure. You can get six bonus points in the Quality category just for being a small practice.

4) Utilize your free resources

  • Check out resources from your specialty society’s website. Many national specialty organizations post free resources for their members, including recommended quality measures or links to qualified registries or qualified clinical data registries to facilitate data collection and reporting. CMS offers a list of approved Qualified Registries for the 2020 performance year, as well as a list of approved Qualified Clinical Data Registries (QCDRs).
  • Reach out to your Technical Assistance Contractor  for free personalized assistance. Find your TAC here.

Tips for Coding Claims for 2020 MIPS Quality Measures

If you’re a small practice, you have the option to report MIPS quality measures as an individual or via group reporting through your Medicare Part B claims in Performance Year 2020. This option is reserved for small practices only (15 or fewer eligible clinicians). If you do not have an Electronic Health Record (EHR), or your software is not fully up to date, you may consider reporting your MIPS quality measures via claims.

If you would like personalized assistance establishing your claims coding process for MIPS reporting, remember to reach out to your Technical Assistance Contractor for free assistance. Several TACs have produced resources to guide your practice through MIPS claims coding. Below are some best practices on how to appropriately code your MIPS quality measures using the Medicare Part B claims submission method:

  1. Select quality measures carefully. Choose at least six of the 55 eligible claims measures that are most meaningful to your practice. You should select at least one outcome measure, or if none are available for your specialty, at least one high-priority measure. To view the available claims measures, see the 2020 MIPS Quality Measures List.
  2. Review claims measure specifications and supporting documents for every measure you have chosen. These resources give you a detailed description of every quality measure and the specific coding requirements to receive full credit for the measure (see the 2020 Medicare Part B Measures Specifications and Supporting Documents). Single Source documents can be particularly helpful in identifying relevant quality measures by allowing you to search for the ICD-10 codes that your practice regularly bills. Additionally, the 2020 Part B Claims Reporting Quick Start Guide provides information on how to get started using Medicare Part B claims to report participation in the Quality performance category.
  3. Define how often you need to report your measures – Some measures only need to be reported once a year, while others are required to be reported more frequently.
  4. Set up an office workflow to ensure that all of your eligible cases can be identified on your Medicare Part B claims. Consider using a billing software that will flag claims every time the combination of codes in a measure’s denominator is billed so that entry of a Quality Data Code (QDC) entry is required before the final claims are submitted. QDCs may include CPT Category II codes (with or without modifiers) and/or HCPCS G-codes for submission of quality data in MIPS.
  5. Submit claims through the regular billing process by adding certain billing codes (QDCs) to denominator-eligible Medicare Part B claims.
  6. Confirm QDC submissions via monitoring of Part B Remittance Advice – Remember toview the information you receive back from your Medicare Administrative Contractor (MAC) in the Remittance Advice or the Explanation of Benefits to see if it the data submission was valid and successful.

For more information on claims coding, see the 2019 Merit-based Incentive Payment System (MIPS) Quality Performance Category: Medicare Part B Claims Data Submission Fact Sheet. Good luck with your coding in 2020 (Year 4)!

How to Connect to Public Health Registries and Clinical Data Exchanges

For the 2020 Performance Year, fulfillment of the Public Health and Clinical Data Exchange Objective is a requirement of the MIPS Promoting Interoperability (PI) Category for all practices that do not meet the exclusion criteria.

The objective’s purpose is to measure if a practice or hospital is “actively engaging” with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record technology (CEHRT). To meet the requirements, practices must attest to two of the five available measures:

  • Immunization Registry Reporting
  • Syndromic Surveillance Reporting
  • Electronic Case Reporting                                    
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting

The Public Health and Clinical Data Exchange objective is worth 10 points in the PI Category. The PI category is worth 20% of the total MIPS score in 2020 (Year 4). Reporting for these measures is a binary yes or no, and practices will receive a full 10 points if they report two “yes” responses. To report a yes, practices should be in one of the three phases which qualify as “active engagement” listed below:

  • Completed registration to submit data. Register to submit data with the PHA to which the information is being submitted; registration must be completed within 60 days after the start of the performance period, and the MIPS-eligible clinician is awaiting an invitation from the PHA to begin testing and validation.
  • Testing and Validation. Begin the process of testing and validation of the electronic submission of data. MIPS-eligible clinicians must respond to requests from the PHA within 30 days; failure to respond twice within a performance period would result in that MIPS-eligible clinician not meeting the measure.
  • Production. Complete testing and validation of the electronic submission and electronically submit production data to the PHA or CDR.

Each of the five objective measures has its own exclusions which are detailed in the 2020 Promoting Interoperability Measure Specifications. Generally, clinicians may be eligible for an exclusion if no relevant agencies or registries in their jurisdiction are able to accept electronic registry transactions in the standards required.

How can you find the appropriate PHA or CDR to engage with? While no official comprehensive list of registries exists, your state’s department of health likely can provide information about what’s available near you. Another great and free resource is your region’s Technical Assistance Contractor. Find your TAC here.

Monthly Observance: Cervical Health Awareness Month

January is Cervical Health Awareness Month in the United States. According to the National Cancer Institute, approximately 13,000 women in the United States are diagnosed with cervical cancer each year, despite the fact that the disease is preventable with vaccination and appropriate screening.

To promote data collection and improvements in cervical health and appropriate screenings, MIPS includes two quality measures focused on cervical cancer screening. Read more about these measures below and consider including them in your reporting to improve care and strengthen your MIPS score.

  • Cervical Cancer Screening (Quality ID 309): Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
    • Women age 21-64 who had cervical cytology performed every 3 years
    • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
  • Non-Recommended Cervical Cancer Screening in Adolescent Females (Quality ID 443): The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer (lower is better).

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